The ethics of extracorporeal membrane oxygenation in brain-dead potential organ donors

Organ Utilization From Donors Following Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review of Graft and Recipient Outcome

BACKGROUND

The global shortage of solid organs for transplantation is exacerbated by high demand, resulting in organ deficits and steadily growing waiting lists. Diverse strategies have been established to address this issue and enhance organ availability, including the use of organs from individuals who have undergone extracorporeal cardiopulmonary resuscitation (eCPR). The main aim of this work was to examine the outcomes for both graft and recipients of solid organ transplantations sourced from donors who underwent eCPR.

METHODS

We performed a systematic literature review using a combination of the terms related to extracorporeal life support and organ donation. Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, PubMed and Scopus databases were searched up to February 2024.

RESULTS

From 1764 considered publications, 13 studies comprising 130 donors and 322 organ donations were finally analyzed. On average, included patients were 36 y old, and the extracorporeal life support was used for 4 d. Kidneys were the most often transplanted organs (68%; 220/322), followed by liver (22%; 72/322) and heart (5%; 15/322); with a very good short-term graft survival rate (95% for kidneys, 92% for lungs, 88% for liver, and 73% for heart). Four studies with 230 grafts reported functional outcomes at the 1-y follow-up, with graft losses reported for 4 hearts (36%), 8 livers (17%), and 7 kidneys (4%).

CONCLUSIONS

Following eCPR, organs can be successfully used with very high graft and recipient survival. In terms of meeting demand, the use of organs from patients after eCPR might be a suitable method for expanding the organ donation pool.

Organ Donation from Patients Receiving Extracorporeal Membrane Oxygenation: A Systematic Review

OBJECTIVE

The mismatch between the demand for and supply of organs for transplantation is steadily growing. Various strategies have been incorporated to improve the availability of organs, including organ use from patients receiving extracorporeal membrane oxygenation (ECMO) at the time of death. However, there is no systematic evidence of the outcome of grafts from these donors.

DESIGN

Systematic literature review (Scopus and PubMed, up to October 11, 2023).

SETTING

All study designs.

PARTICIPANTS

Organ recipients from patients on ECMO at the time of death.

INTERVENTION

Outcome of organ donation from ECMO donors.

MEASUREMENTS AND MAIN RESULTS

The search yielded 1,692 publications, with 20 studies ultimately included, comprising 147 donors and 360 organ donations. The most frequently donated organs were kidneys (68%, 244/360), followed by liver (24%, 85/360). In total, 98% (292/299) of recipients survived with a preserved graft function (92%, 319/347) until follow-up within a variable period of up to 3 years.

CONCLUSION

Organ transplantation from donors supported with ECMO at the time of death shows high graft and recipient survival. ECMO could be a suitable approach for expanding the donor pool, helping to alleviate the worldwide organ shortage.

Treating the dead; how far ought medicine go to obtain transplantable organs?

Under what circumstances, is it ethical to perform tumor surgery on a brain-dead individual? The neurosurgeons at Brigham and Women's Hospital were recently faced with such a question when asked to operate on a 28-year-old man who was pronounced brain-dead secondary to a severe brain-stem injury. His advanced directives clearly documented a desire for organ donation. During his transplant work-up, cranial imaging suggested a possible cerebellar mass of unknown etiology that was concerning for metastatic disease. Despite negative full body imaging, the neurosurgical team was asked to perform an open biopsy of the intracranial lesion to rule out occult systemic cancer. This case invites many nuanced questions related to the decisions surgeons and the broader medical community must make in the face of pursuing viable organs for the many in need. What is the moral standing and personhood eligibility of brain-dead individuals? What is the scope of medical interventions and procedures that surgeons are ethically bound to carry out? How ought the desire for increased medical intervention to try to save organs be balanced with practical limitations given limited medical resources?

Trauma Surgeons' Perceptions of Resuscitating Lethally Injured Patients for Organ Preservation

BACKGROUND

Trauma surgeons face a challenge when deciding whether to resuscitate lethally injured patients whose organ donor status is unknown. Data suggests practice pattern variability in this setting, but little is known about why.

MATERIALS AND METHODS

We conducted semi-structured interviews with trauma surgeons practicing in Level 1 or 2 trauma centers in Tennessee. Interviews focused on ethical dilemmas and resource constraints. Analysis was performed using inductive thematic analysis.

RESULTS

Response rate was 73% (11/15). Four key themes emerged. All described resuscitating patients to buy time to collect more definitive clinical information and to identify family. Some acknowledged this served the secondary purpose of organ preservation. 11/11 participants felt a primacy of obligation to the patient in front of them even after it became apparent, they could not personally benefit. For 9/11 (82%), the moral obligation to consider organ preservation was secondary/balancing; 2/11 (18%) felt it was irrelevant/immoral. Resource allocation was commonly considered. All participants expressed some limitation to resources they would allocate. All participants conveyed clear moral agency in determining resuscitation extent when the goal was to save the patient's life, however this was less clear when resuscitating for organ preservation. Across themes, perceptions of a "standard practice" existed but the described practices were not consistent across interviewees.

DISCUSSION

Widely ranging perceptions regarding ethical and resource considerations underlie practices resuscitating toward organ preservation. Common themes suggest a lack of consensus. Despite expressed beliefs, there is no identifiable standard of practice amongst trauma surgeons resuscitating in this setting.

[Organ donation: A treatment option in end-of life intensive care?]

A newly issued policy statement of the German Medical Association considers organ donation as an integral part of end-of-life intensive care in patients with devastating brain afflictions. Hence, patients' wishes towards organ donation and medical suitability should be evaluated when prognosis is considered futile and goals of treatment need to be reconsidered. Continuation of intensive care treatment towards the (mandatory) diagnosis of "brain death" and subsequently towards organ donation has to be legitimatized by patients' explicit wishes (organ donor card, advanced directive) or by surrogate decisions makers. Intensive care facilitating organ donation should be goal-directed and follow established guidelines. Thus, a potential recovery of transplantable organs is supported by appropriate intensive care treatment. Decisions to employ extended intensive care options (like extracorporeal circulatory support or cardiopulmonary resuscitation) in potential organ donors should be carefully outbalanced with patients' wishes, organ donation being considered an achievable goal and even potential frictions in medical teams.

Ethics in extracorporeal life support: a narrative review

During 50 years of extracorporeal life support (ECLS), this highly invasive technology has left a considerable imprint on modern medicine, and it still confronts researchers, clinicians and policymakers with multifarious ethical challenges. After half a century of academic discussion about the ethics of ECLS, it seems appropriate to review the state of the argument and the trends in it. Through a comprehensive literature search on PubMed, we identified three ethical discourses: (1) trials and evidence accompanying the use of ECLS, (2) ECLS allocation, decision-making and limiting care, and (3) death on ECLS and ECLS in organ donation. All included articles were carefully reviewed, arguments extracted and grouped into the three discourses. This article provides a narrative synthesis of these arguments, evaluates the opportunities for mediation and substantiates the necessity of a shared decision-making approach at the limits of medical care.

Ethical challenges of adult ECMO

The use of extracorporeal membrane oxygenation (ECMO) is expanding rapidly, and as more centres streamline their management policies, the bioethics literature on ECMO has been highlighting the ethical challenges of using an expensive, resource-intensive technology including its eligibility, duration of support, cost-effectiveness and societal repercussions. The absence of high-quality studies on long-term outcomes of ECMO survivors leads to multiple ethical problems involving patient autonomy, beneficence and clinical wisdom pertaining to its initiation, maintenance and termination. This article reviews some of the ethical challenges that affect decision-making during ECMO therapy and suggests an ethical framework that may help the treating team deal with such conundrums, when the patient does not recover despite being on ECMO.

Intensive care for organ preservation: A four-stage pathway

Objective

Intensive care for organ preservation (ICOP) is defined as the initiation or pursuit of intensive care not to save the patient's life, but to protect and optimize organs for transplantation.

Analysis

When a patient has devastating brain injury that might progress to organ donation this can be conceptualized as evolving through four consecutive stages: (1) instability, (2) stability, (3) futility and (4) finality. ICOP might be applied at any of these stages, raising different ethical issues. Only in the stage of finality is the switch from neurointensive care to ICOP ethically justified.

Conclusion

The difference between the stages is that during instability, stability and futility the focus must be neurointensive care which seeks the patient's recovery or an accurate neurological prognostication, while finality focuses on withdrawal of life-sustaining therapy and commencement of comfort care, which may include ICOP for deceased donation.

Extracorporeal Life Support in Organ Transplant Donors

Background

Extracorporeal life support (ECLS) can be applied in brain-dead donors for organ perfusion before donation, thereby expanding the donor pool. The aim of this study was to examine the benefits and early clinical outcomes of ECLS for organ preservation.

Methods

Between June 2012 and April 2017, 9 patients received ECLS with therapeutic intent or for organ preservation. The following data were collected: demographics, purpose and duration of ECLS, cause of death, dose of vasoactive drugs, and need for temporary dialysis before organ retrieval. The early clinical outcomes of recipients were studied, as well as survival and graft function at 1 month.

Results

ECLS was initiated for extracorporeal cardiopulmonary resuscitation in 5 patients. The other patients needed ECLS due to hemodynamic deterioration during the assessment of brain death. We successfully retrieved 18 kidneys, 7 livers, and 1 heart from 9 donors. All organs were transplanted and none were discarded. Only 1 case of delayed kidney graft function was noted, and all 26 recipients were discharged without any significant complications.

Conclusion

The benefits of protecting the vital organs of donors is significant, and ECLS for organ preservation can be widely used in the transplantation field.

Cardiac Graft from Donors with Extracorporeal Support-A Report of Two Cases

The persistent global shortage of organ donors is still a major limitation for transplantation. Experiences of heart transplantation from donors with extracorporeal support are rare. Here, we report from two cases of donors who were supported by extracorporeal membrane oxygenation due to acute circulatory failure. In both cases, the direct postoperative course was uneventful and free from major complications. The patients were discharged to a rehabilitation clinic. Our experience suggests that the use of heart organ from carefully selected donors with extracorporeal support is possible and may lead to an excellent outcome.

Brain-Dead Donors on Extracorporeal Membrane Oxygenation

OBJECTIVES

To describe donors after brain death with ongoing extracorporeal membrane oxygenation and to analyze the outcome of organs transplanted from these donors.

DESIGN

Retrospective analysis of the national information system run by the French Biomedicine Agency (CRISTAL database).

SETTING

National registry data of all donors after brain death in France and their organ recipients between 2007 and 2013.

PATIENTS

Donors after brain death and their organ recipients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the study period, there were 22,270 brain-dead patients diagnosed in France, of whom 161 with extracorporeal membrane oxygenation. Among these patients, 64 donors on extracorporeal membrane oxygenation and 10,805 donors without extracorporeal membrane oxygenation had at least one organ retrieved. Donors on extracorporeal membrane oxygenation were significantly younger and had more severe intensive care medical conditions (hemodynamic, biological, renal, and liver insults) than donors without extracorporeal membrane oxygenation. One hundred nine kidneys, 37 livers, seven hearts, and one lung were successfully transplanted from donors on extracorporeal membrane oxygenation. We found no significant difference in 1-year kidney graft survival (p = 0.24) and function between recipients from donors on extracorporeal membrane oxygenation (92.7% [85.9-96.3%]) and matching recipients from donors without extracorporeal membrane oxygenation (95.4% [93.0-97.0%]). We also found no significant difference in 1-year liver recipient survival (p = 0.91): 86.5% (70.5-94.1) from donors on extracorporeal membrane oxygenation versus 80.7% (79.8-81.6) from donors without extracorporeal membrane oxygenation.

CONCLUSIONS

Brain-dead patients with ongoing extracorporeal membrane oxygenation have more severe medical conditions than those without extracorporeal membrane oxygenation. However, kidney graft survival and function were no different than usual. Brain-dead patients with ongoing extracorporeal membrane oxygenation are suitable for organ procurement.

Evaluation and Management of the Potential Lung Donor

The expansion of the donor lung pool has involved an evidence-driven redefinition of acceptable donors. Proceeding with transplantation with an acceptable rather than ideal donor depends on specific patient-related and organ-related risk factors as well as the severity of recipient illness. Although the physiologic optimization of brain-dead donors has not changed significantly in recent years, the use of donor management protocols has improved procurement rates. Ex vivo lung perfusion is an increasingly viable strategy to recondition lungs that would otherwise fall below the acceptable threshold for transplant. Ex vivo perfusion trials for preservation of standard donor lungs are ongoing.

Extra corporeal membrane oxygenation support: ethical dilemmas

The vast expansion of patients treated with of extra corporeal membrane oxygenation (ECMO) emerge novel ethical questions about the use of this new technology. In regard the indications, duration of support and timing of withdrawal of support, these questions sometimes create disagreement among surrogates, between health care team and surrogates, and even disagreement among health care team, these disagreements occurs because of the extreme emergency of support initiation, the ambiguity of the outcome as well as lack of clarity on the intended treatment direction, whether it is ineffective, bridge to recovery or bridge to lifetime mechanical support or transplant. In this article we discuss these questions through patients' scenarios.

Uncontrolled Donation After Circulatory Determination of Death: A Systematic Ethical Analysis

Uncontrolled donation after circulatory determination of death (uDCDD) refers to organ donation after a refractory cardiac arrest. We analyzed ethical issues raised by the uDCDD protocols of France, Madrid, and New York City. We recommend: (1) Termination of resuscitation (TOR) guidelines need refinement, particularly the minimal duration of resuscitation efforts before considering TOR; (2) Before enrolling in an uDCDD protocol, physicians must ascertain that additional resuscitation efforts would be ineffective; (3) Inclusion in an uDCDD protocol should not be made in the outpatient setting to avoid error and conflicts of interest; (4) The patient's condition should be reassessed at the hospital and reversible causes treated; (5) A no-touch period of at least 10 minutes should be respected to avoid the risk of autoresuscitation; (6) Once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation; (7) Specific consent is required prior to entry into an uDCDD protocol; (8) Family members should be informed about the goals, risks, and benefits of planned uDCDD procedures; and (9) Public information on uDCDD is desirable because it promotes public trust and confidence in the organ donation system.

Ethics Committee Consultation and Extracorporeal Membrane Oxygenation

RATIONALE

The clinical ethics literature on extracorporeal membrane oxygenation (ECMO) has been focused primarily on identifying hypothetical ethical dilemmas that may arise with the use of this technology. Little has been written on the actual experience with ECMO-related ethical questions.

OBJECTIVES

To describe the role of an ethics consultation service during the expansion of a single-center ECMO program in a cardiothoracic surgery intensive care unit (CSICU) and to identify common ethical themes surrounding the use of ECMO.

METHODS

We conducted a retrospective, descriptive cohort study of all ECMO ethics consultation cases in the CSICU at a large academic hospital between 2013 and 2015.

MEASUREMENTS AND MAIN RESULTS

During the study period, 113 patients were placed on ECMO in the CSICU, 45 (39.5%) of whom were seen by the ethics committee. In 2013, 10 of 46 (21.7%) patients received ethics consults. By 2015, 28 of 30 (93.3%) of patients were seen by ethics consultants. Initial consultation occurred at a median of 2 days (interquartile range, 1-6 d) following initiation of ECMO. The most common ethical issue involved disagreement about the ongoing use of ECMO, which included multiple axes: Disagreement among health care providers, disagreement among surrogates, and disagreement between health care providers and surrogates over stopping or continuing ECMO.

CONCLUSIONS

In our experience with integrating ethics consultation into the routine care of ECMO patients, most of the ethical questions more closely resembled traditional concerns about the appropriate use of any life-sustaining treatment rather than the novel dilemmas imagined in the current literature.